Asthma in the Real World: Stories and Solutions

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"Recent studies have looked at the ability, even in severe asthmatics, to achieve extremely good control of their asthma. If we're able to do that, individuals should be able to exercise at any level. They should be able to go to work and not miss days, same thing with school. Truthfully, the sky's the limit as long as your asthma is under control."
- Dr. Wendell Richmond

At times, you may feel alone with your disease. The truth is that many asthmatics share the same frustrating symptoms and emotional rollercoaster ride. Hear from other HealthTalk Asthma Education Network members and share your own stories about how asthma has affected your quality of life. Find solutions for coping with and controlling this potentially dangerous but generally manageable disease.

This program is produced by HealthTalk and sponsored through an unrestricted educational grant from Genentech and Novartis.

Announcer:
Welcome to this HealthTalk webcast. Before we begin, we remind you that the opinions expressed on this webcast are solely the views of our guests. They are not necessarily the views of HealthTalk, our sponsors or any outside organization. And, as always, please consult your own physician for the medical advice most appropriate for you.

Rick Turner:Missed work days, school absences, trips to the hospital - if these circumstances are part of your daily life, chances are your asthma is not under control. Tonight, we're going to look at the true impact of asthma on patients' lives, and we'll offer solutions for coping with and controlling your disease.

We're pleased to have with us two medical professionals who have dedicated their lives to helping asthma patients manage their disease. First, I'd like to introduce to you Dr. Wendell Richmond, who is an allergist practicing at Oakbrook Allergists in Oakbrook, Illinois. Also on the panel with us tonight from Oakbrook Allergists is registered nurse Donna Staszak.

And now I'd like you to meet Carol Mersman. Carol is an asthma patient. She is a Chicago area resident, and she was kind enough to join us tonight. Thanks for being here, Carol.

Carol Mersman:Thank you for inviting me.

Rick:How did you first learn that you had asthma?

Carol:My parents took me to my pediatrician when I was 10 years old. I would spend time at friends' houses who had animals, and I would come home wheezing and sneezing, and they finally realized that they needed to do something about it.

Rick:Did they realize immediately that it was asthma?

Carol:No, they did not. They thought it was just allergies. It took a few times going to the doctor to make that diagnosis.

Rick:You've lived with it for a number of years. Do you know what triggers your attacks?

Carol:Yes, I do - ragweed, cigarette smoke and definitely pet dander.

Rick:I'm sure over the years there have been highs and lows, probably for you in dealing with asthma. Do you want to share, maybe, a particularly low moment with us?

Carol:Definitely lows were Christmas Eves at my in-laws house. They had two puppies and a live Christmas tree. After visiting their house, I would go to the emergency room, so that was not a fun experience.

Rick:Overall, how would you say that asthma has impacted your quality of life, Carol?

Carol:I really restricted myself to being at friends' houses with animals, also being outside during tree or ragweed season.

Rick:
Did you avoid exercise?

Carol:Yes, I would [avoid exercise] because I would be short of breath, all the time.

Rick:Over the years, give us a litany of the treatments you have received.

Rick:Tell us now about your current treatment plan and how it's working for you, Carol.

Carol:My current treatment plan is that I'm on Advair 100 [salmeterol/fluticasone], the lowest dose. I also am on Xolair [omalizumab], once a month. It's working great. I do not use my albuterol at all. It's working wonderful[ly].

Rick:How is your quality of life today? Compare it to five years ago.

Carol:I don't even know I have the disease anymore except for that once a month when I get my Xolair injection. I don't even realize I have asthma.

Rick:I'm glad everything is working for you, and I'm glad you're here with us tonight.

Carol:Thank you.

Rick:Let's turn now, back to Dr. Richmond. Listening to Carol's experience, do you think it's typical of the sort of patients you see in your practice?

Dr. G. Wendell Richmond:Yeah, I would say that's probably fairly typical. Certainly, asthma is a spectrum disease going from mild to someone as severe as what Carol was. But I think for people with more persistent disease, that's not atypical of what we hear.

Rick:Like Carol, each allergic person has personal triggers that his or her own immune system will essentially overreact to. There are common triggers, we've mentioned some already, that people with allergic asthma are particularly susceptible to: animal dander, dust mites, mold exposure, for example. Why is it important for a person with allergic asthma to identify what his or her personal triggers are?

Dr. Richmond:
I think once they understand what their personal triggers are, hopefully they can attempt to avoid those things. As Carol suggested, some of those things are hard to avoid. In fact, if they are seasonal problems or family involvement, sometimes that's difficult. But, ideally, we can avoid it and if not, maybe we can approach therapeutically in a little different way that might decrease the frequency and severity of those symptoms.

Rick:In terms of figuring out what a person's personal triggers are, how do you do that?

Dr. Richmond:There are a couple of different ways. Certainly, a very important thing is the history. We spend a lot of time taking a history, hopefully a fairly detailed history to understand what a trigger would be - basically, the patient teaching the physician because they know their history.

Once we sort of get an idea from the history of what's going on, then certainly we can take a look if allergens are a factor. Then we can take a look at trying to identify what allergens are problematic.

Rick:How do you do that?

Dr. Richmond:That would be in looking at the ability to identify allergy antibody to things like trees, grass molds, house dust, cockroaches in certain situations. That can be [done] by skin testing [or] that can be doing blood tests.

Rick:Tonight, we'll hear examples of some of the common situations and symptoms that people with asthma face. When we talk about how to avoid personal triggers, we're usually talking about avoidance strategies at home - an environment over which you have some control. In the great outdoors, however, you may not have as much control. Dr. Richmond and Donna, please respond to this case study dealing with seasonal triggers.

Case History #1:I have moderate asthma, and my triggers are pollen and mold. I use my rescue inhaler a lot more in the spring and when the humidity is high. How do I keep my asthma under control in the spring and summer?

Dr. Richmond:If we have an individual who has that type of exposure, we would like to decrease the amount of exposure. That can be done in a couple of different ways. Obviously, [the] number one [thing is] the patient understanding what the problem is and then trying to avoid that. We can do that by such things as air conditioning. Air conditioning helps a great deal. I think that modifying our therapeutic approach would be of some benefit.

Rick:Before we go to you, Donna, I want to get Carol's input on this and see if she has some personal experience in avoiding seasonal triggers.

Carol:When I would plan my day for outside, I would, like Dr. Richmond said, increase my medication. I would do an extra nasal spray to prevent myself from having any asthma or allergy attacks.

Rick:What would you add to this, Donna?

Donna:One of the things that we've talked about with some of our patients that is helpful is keep the pollen outside. Don't bring it indoors with you. [Try] washing your hair at night before bed. Do it twice. Keep the pollen off your pillow. Wash your pillow cases a little more frequently than maybe once a week. Some of those things can help. Oftentimes, just your animals, if you have any animals in the house, the animals carry a lot of dander as well, so then they are bringing the allergen in with them as well. They're moving it to furniture and pillows and carpeting. You just really have to try to monitor how much of the outside actually does get in especially during the peak times. Pre-medicate. Take the medication every day in high season when you're bothered even if you don't want to. A lot of people don't want to take medicine every day, but you really do need to.

Rick:Geography also has an effect on personal triggers. Our next case study questions whether moving to a different part of the country can improve one's asthma symptoms.

Case Study #2:My daughter grew up in the Pacific Northwest, and now she lives in the Las Vegas area. Her asthma seems worse since she relocated. Is there someplace she can move to escape seasonal triggers?

Rick:Now, initially, I was surprised to hear that because I would think there's more pollen in the Pacific Northwest. [When] you move to the desert, it should improve, but just the opposite is the case.

Dr. Richmond:I think that's the thing that we're seeing nowadays. [Say] 30, 40 years ago, we'd say,
"Well, move to the Southwest, and things are going to get better." I think we've seen everybody move to the Southwest. Unfortunately, they've brought all their plants. There is frequently as much as a problem down there with pollens as there are up here. People have imported ragweed and everything else in that particular area. Where can you go nowadays? Well, I'll tell people the place I would like to be, you can imagine you're in the Hawaiian Islands, and you're in the Pacific side with the winds blowing on you. That's a wonderful place.

Rick:Sounds good to me.

Dr. Richmond:An ocean breeze, and you can possibly pick [the] North or South Pole, but beyond that you're really going to be in trouble. I think this case brings up another point. Allergic individuals are genetically predisposed to be allergic. An individual who has allergies will see a change in their allergies over time. So if you move from location A to location B, generally the suggestion is that within three years of that move, you'll start having symptoms to those pollens which are in that area. You can never totally escape because genetically you've been given that gift of being allergic.

Rick:Donna, do you want to add anything to that?

Donna:I think that patients will say that, especially as they near their retirement years, "Where's the best place I can go so I don't have to deal with what I've been dealing with now?" I think that it's just patient education that there is not a place. Eventually, you'll become allergic to the tumbleweed in Texas. It doesn't matter. Again, it's controlling the disease, staying on those medications even when you feel great. It's here with you, and it's going to stay.

Rick:Another difficult issue for people with asthma is pets. I'm sure you've talked about it a lot in your office. Let's listen to our next case study and have our panel respond.

Case Study #3:One of my worst asthma triggers is my dog. I'm really good about taking my medications, but I'm still sensitive to the dander. Is there anything else I can do, short of giving my dog away?

Dr. Richmond:Fido is making the individual sick. The correct answer is, you should guess it, is the dog moves to Cleveland, and she stays here.

Rick:Short of that?

Dr. Richmond:I will tell patients that, and, of course, they look at me and just simply shake their head and say, "That's not going to happen." If we know the pet's going to be causing a problem, then we would like to keep that pet out of the one area we spend most of our time. That is the bedroom because if you sleep eight hours a day, that's one-third of your day in one area. Obviously, trying to keep the bedroom as pet-free as possible is a distinct advantage. Then we get into the questions, "Should I wash my pet?" Does that seem to decrease the amount of allergen that's coming from this particular pet? Studies have shown that in fact washing your pet can decrease the amount of allergens. Studies have shown that actually you might need to wash your pet at least twice a week for it to be most effective.

Rick:
Washing a cat?

Dr. Richmond:Washing a cat with claws would be very difficult, I must say. That would be difficult. The other thing, of course, is "Well, should I buy an air purifier? Will that help out?" We get that question a lot. The good thing is yes, some of the air purifiers, and in fact most air purifiers will decrease the amount of pet, whether it be cat, dog, your friendly guinea pig, will decrease that type of allergen in the air.

Rick:[Do you have] anything to add on the issue of pets that you've dealt with, Donna?

Donna:We all want to be in control, so I think they just have to vacuum much more frequently, preferably have someone else vacuum, which would probably be better. The new vacuum cleaner systems that are out there today are helpful to patients as well, the bag-free ones are much better. And, of course, keeping the pet out of their area [will help].

Rick:More than 20 million Americans have asthma, but research shows that many asthmatics could be doing more to control their disease and reduce the symptoms. We've mentioned control quite a few times already tonight. Dr. Richmond, please define for us what it means to have control of your asthma.

Dr. Richmond:There are five areas which would identify control. Number one, we would want to make sure that individuals are symptom-free, or as close to being symptom-free of their asthma as possible. The second would be to decrease the frequency of exacerbations - how frequently you're going to have asthma [symptoms]. We would have no exacerbations or very few. Activity levels - activity levels whether in fact they be your social activity levels or exercise activity levels - they should be normal. We shouldn't want to see anyone be limited by any means by their asthma, and I think that's a very important point. Unfortunately, all too often people will use the excuse, "I've got asthma. I should not have my activities."

I think also as little rescue medication [as possible] is an important point. Relatively normal or near normal pulmonary function data is an important thing that we would like to have. Finally, something that is near and dear to patients' hearts is that they would like to be on some sort of medication that is going to be very safe and well-tolerated.

Rick:What about the issue of sleeping through the night - how important is that when you're under control?

Dr. Richmond:That's a very good point. One of the major problems in individuals when their asthma is exacerbating is that they will wake up in the middle of the night. That is something that if the asthma is under excellent control, they should never be waking up.

Rick:As far as having pets, we're asking the question is asthma controlling you or the other way around. If you're avoiding pets because of your asthma, in a sense, that's controlling you, right?

Dr. Richmond:[That's] exactly right.

Rick:I understand that when asthma is in control, patients really should not be limited in any way. What is achievable despite having asthma?

Dr. Richmond:I think that recent studies have looked at the ability, even in severe asthmatics, to achieve actually extremely good control of their asthma. If we're able to do that, individuals should be able to exercise at any level. They should be able to go to work and not miss days from work, same thing with school. Truthfully, the sky's the limit as long as your asthma is under control.

Rick:Certainly, we have seen TV commercials of Olympic athletes with asthma.

Dr. Richmond:The fastest woman in the world used to be an asthmatic. That goes to show that if you take control over your asthma, that the asthma is not going to take control of you.

Rick:There are different classes of asthma medications. What are the differences between long-term control medications such as inhaled corticosteroids, for example, and quick-relief medication such as albuterol?

Dr. Richmond:
Albuterol is as defined, it's a quick-relief medication. It will provide rapid onset of improvement in symptoms, ideally, within three to five minutes. It will have a duration of effect from anywhere between two and six hours. What albuterol will not do is treat the inflammation within the airway. Albuterol is a quick-fix medication. It is not a long-term medication. It's not intended to really treat individuals who have more persistent symptoms.

Long-term control medications are medications which will decrease the inflammation within the wall of the airway. Again, [this is] extremely important to individuals who have more persistent symptoms. Those are medications which will change the course of your disease in the long-term and hopefully will prevent long-term adverse events from your asthma.

Rick:Doctor, give us some of the different classifications of asthma drugs. We've mentioned corticosteroids, and [there are] also bronchodilators, leukotriene modifiers, IgE blockers. Give us a primer on what we have to deal with here.

Dr. Richmond:
Leukotriene modifiers - the medicine that's probably best known right now is Singulair [montelukast]. Singulair inhibits that particular molecule from binding to its receptor and causing marked bronchoconstriction. Singulair comes at treating asthma by a different mechanism than even inhaled corticosteroids. Other medications include [cromolyn sodium or nedocromil, brand names Intal or Tilade]. Those particular medications are very effective, extremely safe, probably not are not nearly as potent as the inhaled corticosteroids as a disease modifier. Those of you who remember good old Theo-Dur, or theophylline compounds, which were the things that I was trained in back in the '70s and '80s, as being the primary medication. [This is] a good medication for treating asthma as we saw during those decades, but again, has been shown not to be nearly as potent as an anti-inflammatory as inhaled corticosteroids. Anti-IgE molecules [is] one of the newer therapies, one of the more innovative things that we now have available to us. IgE is very important in causing asthma, and if we decrease the amount of IgE we will decrease the likelihood of having asthma.

I'd like to mention one other area, which is sometimes is not considered a classic therapeutic agent, that is, allergy shots. Allergy shots have been shown, over time, to decrease the likelihood of developing asthma in the pediatric population. It is not an immediate therapy for asthma but will decrease the frequency and severity of symptoms in a number of individuals.

Rick:
With each of these categories of medicine, if you could for us, Dr. Richmond, touch on who they're appropriate for and some of the side effects to be concerned about.

Dr. Richmond:Fortunately, most of these medications are appropriate for almost everyone. Nowadays, we're starting to see that the medications are approved for the pediatric population. Inhaled corticosteroids, which are very appropriate in the pediatric population, are always a concern. Other medications in the pediatric population would be [cromolyn sodium or brand name Intal], a medication which is poorly absorbed and can be very effective with minimal side effects. The use of [short-acting] beta-agonists, that being albuterol, is very safe in that population. The critical thing is we have to control that inflammation in the airways to keep people well in the long term.

Rick:One of the last categories of drugs that you mentioned, the IgE blockers, Xolair [omalizumab] [is] a brand name. For whom would that be appropriate?

Dr. Richmond:Xolair right now has an indication for individuals [who have] moderate to severe [allergic] asthma - individuals who have not had tremendous success with the classic therapeutic approaches that we've talked about, individuals who have not responded appropriately to albuterol, individuals who have subsequently been placed on more aggressive inhaled corticosteroids, and they are not having adequate responses. Not to say that they don't have responses, but [they are not having] adequate responses or are having frequent exacerbations of their asthma when they are taking that type of medication.

Rick:Let's talk about the importance of taking medication regularly and correctly. How do you help patients who are having a difficult time following their medication routine?

Dr. Richmond:It's a very difficult issue. Compliance is the number one issue in taking care of asthma. I think that if we take a look at the national guidelines that have been available now for well over 10 years, the data has shown in numerous different studies that if patients are compliant, well over 80 percent of individuals, if you're simply compliant, will have extremely good control of asthma. Compliance is a major thing. The problem we have right now is we have some individuals who don't want to take a medication or have a problem taking this medication.

I think as people become more educated of concern about side effects from medications, physicians or healthcare providers, we need to teach them that these medications are safe, to understand what the problems of that medication are, so they can either watch for those problems, predict those problems or as they go along, realize that the medication is not a big problem.

Rick:Donna, how do you work with your patients to ensure that they're getting the most out of their treatments?

Donna:I think that one of the number one things is that any time that we are able to sit down with the patient at an office visit is to make sure they understand that they need to be seen three to four times a year for asthma. Asthma is not a disease that goes away. They may feel better - they should still continue to take their medications. Keeping medications in a place in the house so that they don't forget [is a good practice]. Most of them today are very easy. They are twice-a-day medications, at best. Put [your medications] on a kitchen table. Put it in the bathroom. Make it part of your daily hygiene before you leave the house, before bedtime. See your physician [regularly] and come to the physician's office with your questions and your concerns.

Dr. Richmond:I think one of the critical things that we have to do as physicians is provide a written action plan. Individuals will frequently go out of the office - they do not understand what the medication is. They don't understand what the medication is for, and all too often physicians are too busy [and] don't spend the time to write down something, to say, "Okay, this is what you do. This is the Betty Crocker cookbook way of taking care of your asthma. As long as you do follow the Betty Crocker cookbook way of taking care of your asthma, you will probably do fairly well."

Rick:Donna, back to you, is there a special challenge when it's the child who has asthma in terms of compliance issues?

Donna:
I think depending on the age of the child [that can be true]. Of course, [with] a younger child, the parent gives the medication, the child takes it. It's very observed, and it's not an issue. As they get older into their pre-teen and particularly their teen years, where they are expected to be more responsible for themselves, we need to just keep reminding them that this disease is always there. Take your medicines, and then you won't get sick from [asthma]. You won't end up in the emergency room.

Simply take the medicine as a controller every single day. You don't want to control the asthma when it's attacking you, it's kind of late. You've got to keep riding on the same issues. Other than carrying albuterol with them, and most of them will tell you if they are using their long-term corticosteroid, they don't even need to have it. But they should have it, and I don't think it's so much of a stigma today. I think that a lot of students carry them in schools. We just try to keep repeating and going over the same thing.

Rick:I'd like both Dr. Richmond and Donna to respond to some more hypothetical case studies we have for you, and here's one from the mother of an asthmatic.

Case Study #4:I have a 12-year-old child with moderate persistent asthma. He has been put on oral steroids many times. What long-term side effects should we be aware of?

Dr. Richmond:One of the first things that we'll see is weight gain. This can be a significant factor in a relatively short period of time. As we go along, we'll see individuals have what's called Cushingoid faces [also called moon face] - that being a rather round looking face as a result of steroids. For people who have ever been on steroids, that can be quite troublesome, and they don't quite look the same as they did before. For a longer period of time after that, we have to consider other things: cataracts, sometimes increasing risk of glaucoma, an increase in blood sugars, which, again, are always a concern, not necessarily that everyone will become diabetic, most people do not. But, again, if you have diabetes, that is a major concern. We have to always be concerned about cholesterol levels going up. Recent data has suggested people on long-term steroids have an increased risk of coronary artery disease as a result, perhaps, of increase in cholesterol levels if there's that association. Corticosteroids in appropriate doses will decrease bone density. In the pediatric population, one of the concerns is bone growth. Is Johnny going to be the 6'5" power forward for the Seattle Supersonics or something like that? That is always a major concern. Those are some of the major abnormalities that we would expect to see in individuals on long-term steroids.

Rick:We have another case study looking at side effects.

Case Study #5:
My asthma was severe as a child, but it's moderate now. The drug Advair [salmeterol/fluticasone] works well for me, but unfortunately I developed laryngitis and thrush from it, despite following directions to the letter. Six months of suffering from these side effects have left me a bit gun-shy of new drugs. Is this a common reaction to drugs with steroids in them?

Dr. Richmond:It's a common adverse event, that being laryngitis or the medical term is dysphonia, where they just lose their voice a little bit. Certainly, it is relatively common. I would say the individuals who have been on inhaled corticosteroids, this loss of voice is not particularly common but without a doubt of some of the effects we do see, yes, and we can see that. The medicine that he mentioned, Advair, in my experience, this is again my experience, is one that seems to do it more than other inhaled corticosteroids, Pulmicort [budesonide], Azmacort [triamcinolone] doesn't seem to have quite the frequency as that as does the Advair. Advair is an extremely effective medication as are all of these medications. But, occasionally, we will see this abnormality.

Rick:What about thrush that he mentioned?

Dr. Richmond:
Thrush is a very common problem. The higher the dose of medication that we use, the more likely we would develop thrush. Thrush is a candidiasis infection in the retropharynx. When you take a look in the back of the throat, it looks like a little bit of cottage cheese sitting in the back of your throat that just doesn't go away. It is frequently dependent upon the dose of the inhaled corticosteroid. Individuals who are on oral steroids also taking an inhaled steroid are at an increased risk of developing thrush. People who are on antibiotics at the same time that they are on higher doses of inhaled corticosteroids will frequently get increased risk of developing thrush. People who are diabetic, who have glucose intolerance will have an increased risk of thrush. So thrush can be a problem.

Rick:Carol, I wonder if you have some life experience with side effects such as we've just heard described and how people might cope with them.

Carol:
When I first started Advair, I also had thrush a couple of times, but I was not following it like I was supposed to. I would not rinse and spit like Dr. Richmond would tell me to. Once I started following the directions better, then I did not have a problem.

Rick:When life circumstances changed, asthma treatments should also change. Doctor, respond to this case study.

Case Study #6:I'm in my first trimester of my second pregnancy. I have some asthma symptoms like getting tired easily and being short of breath. Sometimes I wake up at night or early morning with a cough. I have two questions. Who should I see for my prenatal care, an asthma specialist or my OB/GYN? And what asthma treatment is safe for a woman in my condition?

Dr. Richmond:
To the first question, who should she see? The answer is she should see both. I think that nowadays obstetricians certainly will work hand in hand with asthma specialists - with the pulmonologist, the allergist and taking care of individuals who are pregnant. That is an important interaction, which will help take care of pregnant asthmatics.

The medications, it's very interesting. There's a lot on the line when someone is pregnant. The question has been, are some of the medications which we routinely use for asthma for unpregnant asthmatics, are they safe during pregnancy? The answer, at this point in time, is yes. We are going to use the same kind of medication in an asthmatic whether in fact they are pregnant or not. During pregnancy, the oxygen level in the fetus is much lower than the mother. If you have an acute exacerbation of asthma, the one who is going to feel it more is the fetus. Therefore, the potential risk for the fetus is actually more during an asthma exacerbation than even for the mother. At this point in time, the recommendations that we use for anyone will be carried through in an asthmatic pregnant individual.

In an individual with mild symptoms, [we'll discuss] the use of a short-acting albuterol inhaler. With people with more persistent symptoms, we'll begin talking about the use of inhaled corticosteroids. There is without doubt the benefit clearly outweighs any risk of that medication during pregnancy.

Donna:I think that women are always very cautious about that. Sometimes we'll get the question from the female population prior to getting pregnant - should I stop taking the medicines - and that probably is the number one question these days. If they are planning a pregnancy, [the answer is] no. You need to stay in control. You need to stay real flatlined. We don't want to be having an exacerbation. You don't want to get sick while you are trying to get into a pregnant state. They just want to have all the information reaffirmed. Oftentimes, it's the same information, and they are hearing it at their OB/GYN's or their family physician or even at their pediatricians because many women seek that opinion of a pediatrician prior to becoming pregnant, too.

Rick:We've spent a lot of time talking about asthma medications and some avoidance strategies. Now let's spend some more time talking about other factors that can contribute to poor asthma management and how we can avoid these pitfalls. Our next case study looks at a patient who has been in denial about their asthma.

Case Study #7:
When I was first diagnosed with asthma, I wouldn't accept that there was anything wrong with me, and I refused to take my medication. Most of the time, I was fine anyway. Then I ended up in the hospital. The doctors told me I nearly died. I didn't even know you could die from asthma. I think it's time to take this disease more seriously. What are the next steps I should take to educate myself?

Rick:Can you die from asthma?

Dr. Richmond:Absolutely, you can die from asthma. Unfortunately, we have seen that happening up till the mid-1990s, which was absolutely amazing. From the '60s on, there was an increased risk of death even though we were doing better taking care of individuals with asthma. Unfortunately, Chicago tends to be one of those areas where we see more asthma deaths than most anywhere else in the country for reasons that are being studied at this point in time.

Rick:
So what does this individual need to do?

Dr. Richmond:I think he's done a major thing. I think he's realized that it's time now to get serious about taking care of his asthma. I think that that in this particular situation, education is going to be the major thing. I think that if he begins to understand what asthma is, what the process is that is causing his asthma to become worse, whether in fact it is allergens, whether it's viral infections, which is a very common cause of asthma exacerbations. I think that right now he is of the understanding that he's going to need to take a medication every day. I like to make one very important point: People think that you have to have bad asthma to die. It's very clear that you can find individuals with mild asthma, and they can die from their asthma. People can have acute exacerbations of their asthma and not be appropriately cared for, and any level of asthma can be a death-defying episode.

Rick:That's sobering to hear. For some people, exercise is an asthma trigger. See if we can get you to respond to the following situation.

Case Study #8:Two of the things that I love to do best - hiking and biking - leave me short of breath. I have tried using my albuterol inhaler before, but it seems to make no difference. What can I do?

Dr. Richmond:Without a doubt, an individual with asthma, if their asthma is not well-controlled, exercise will routinely do it. There's certainly this subgroup of individuals who have exercise-induced asthma, which does not have a severe connotation to it at all - only occurs with exercise. This is a case that's a little bit more disturbing to me because this individual is using their albuterol inhaler. A good 94 to 95 percent of individuals, if they use an albuterol inhaler before exercise, will be able to curb their asthma if they simply have exercise-induced symptoms. If this individual has more persistent symptoms, then unfortunately an albuterol inhaler still should be of some benefit. He would need to be seen. I think the severity of his asthma would have to be better identified. There are other medications which will help out in this situation. Right now, classically, leukotriene modifiers, Singulair [montelukast], has been shown to be very effective in exercise-induced symptoms.

Donna:I think also if they are only taking albuterol, I would wonder if they've been followed properly. Pulmonary function testing, the patient comes in and does a breathing test at least once a year to see where they are at in terms of their disease, is a great comparison for a physician and the patient. It's a visual tool that they can use to actually monitor and track how they are doing, and they can look at that and say, "But I don't feel that bad." And that's because they are not in control. Again, office visits, communication with the patient and constant teaching for them [are good practices].

Dr. Richmond:
Exercise-induced asthma has become a very popular phrase for individuals nowadays, especially the pediatric population. A recent study just took a look at a group of individuals who had exercised-induced breathing problems. It turns out that a proportion of these individuals, generally 35 to 40 percent had exercise-induced asthma. Other individuals simply had exercise-induced dyspnea, which is just shortness of breath, [that] could be from a lack of conditioning or other problems. Again, not everything that wheezes is asthma, and not all asthma wheezes. We are seeing a lot of individuals with exercise-induced vocal cord dysfunction where there is nothing wrong inside the chest. It is a problem in the upper airway that individuals are having trouble getting air into their lungs. It's a problem at the vocal cord level, and, again, it would not be expected to respond appropriately to albuterol. We need to use these subtle clues as clinicians to understand if this person has asthma or has a combination of something else.

Rick:We've touched on exercise a couple times tonight, but let's address it directly. Used to be the thinking was that if you had asthma, that was a reason to avoid exercise. What's the thinking today?

Dr. Richmond:I think the thinking today is just the opposite. As an individual who takes care of asthma, my goal is to have that person treated with appropriate medications so that they can exercise at any level that they would so choose. If they have the ability to be an Olympic athlete, they should be able to go out and do that and be a world champion.

Donna:I think that that's true today. I think that years ago, you saw patients, particularly small children, who were held back because their disease got out of control if they ran around the playground too much or if they joined the baseball team, or [if] they ever ran track. But today, we as parents and as health providers want to see children more involved and more active for various reasons, and we shouldn't shy away from it. We should work together with the physician, the pediatrician, allergist, pulmonologist, to make sure that the child with asthma or even exercise-induced bronchospasm can certainly perform their activity.

Rick:As we just heard, exercise is a realistic possibility for people whose asthma is under control. Let's start our audience questions.

Stephanie:I want to ask a question about exercise-induced asthma. I'm a triathlete. I have [been] training for my first race about five months. My trainer said that I should carry my albuterol with me during the course of the event. It's a half-mile swim, 12-mile bike ride and 3-mile run. Obviously, with the bike and the run, it's a little more practical, but I just wanted to know what else you might recommend since it would be hard to swim with an inhaler attached to you. Thanks.

Dr. Richmond:That's a very good point. Congratulations on doing that. I think that's wonderful. Fortunately, if you use the albuterol ahead of time, in theory, you should be able to get a good two hours out of it and maybe even longer than that. What's interesting is we run into these problems of individuals where we might need to use longer-acting medications. In that situation, we have a couple different choices, maybe even three different choices. The first choice is using a long-acting beta-agonist. Those are available nowadays, and one of them being Serevent [salmeterol], the other one being Foradil, which are two brand names. Foradil [formoterol] has a relatively rapid onset of action within generally three to five minutes with the duration of effect somewhere around 12 hours. Again, Serevent has a little longer onset of action about 48 minutes, but again, will last about 12 hours. Some individuals, for exercise-induced symptoms, will use that. Again, a very good medication for exercise induced symptoms is a leukotriene modifier - Singulair being the classic medication nowadays. Now, again, that does not have a rapid onset of action. Generally, it will take about 24 hours before we see much of anything from this medication. But, again, that would have a much longer duration of effect. Those would be certainly two considerations, and some individuals who have more persistent symptoms other than simply exercise-induced symptoms we will then put them on inhaled steroids with a long-acting beta-agonist, something like Advair, at this point.

Rick:We're going to start with an e-mail question first tonight from Frank in Norfolk, Virginia who e-mailed us this question, "Is it true that Xolair's effectiveness increases the longer you use it?"

Dr. Richmond:Xolair [omalizumab] is anti-IgE antibody. The data has shown at this point in time that we need to administer Xolair over approximately four to six months to see if, in fact, there is an effect. Will things progressively improve? We have seen, in our experience, in our group here that over that first year that we will see some improvement. Usually, the slope of the curve of improvement will be very steep, at least initially, within that first six-month period of time. It will then begin to flatten off, but, again, we'll continue to see some improvement over time.

Rick:Carol, did you want to comment on your experience with Xolair?

Carol:I just had my 23rd shot today, and my medication level has decreased significantly since I first started. I notice the difference starting at month three. I definitely see a difference.

Rick:I'm sure we did touch on this earlier, but let's talk about how Xolair is administered.

Dr. Richmond:
Xolair, it is an antibody against IgE. It is an injectable medication. It is not intravenous. It is simply going to be an injection into the muscle. It's given in either every two to four weeks intervals. At this point in time, the recommendations are to be given within the physician's office. I think that what we will see over time, that might change with it being shown to be extremely safe medication.

Rick:Next, we have an e-mail from Janet in California who writes, "I've been diagnosed with asthma and COPD. How do I know which problem I'm having when I have an episode?"

Dr. Richmond:COPD is chronic obstructive pulmonary disease, most classically associated with individuals who have smoked. Amazingly, up to a fourth of adult asthmatics continue to smoke. So we do see some overlap in COPD. Now, is COPD, simply from smokers? No, we can have COPD from other respiratory trauma whether it be some individuals inhaling organic dusts, other different types of things. But again, that's going to be the classic precipitating factor for COPD. It's a difficult thing because there are individuals who have a wheezy COPD and there are individuals who have asthma and COPD. Fortunately, the therapy is going to be about the same. For individuals who have a wheezy episode, whether that's COPD or asthma, nowadays, it's going to be initially a short-acting beta-agonist. In some individuals with COPD and asthma, that a second medication will be added on called [ipratropium bromide] which has better effect with individuals with COPD than asthmatics. This is a medication which goes by the name of Combivent, it's a combination of albuterol plus [ipratropium bromide]. How would we figure this out? I think number the one thing is to have a measure of one's breathing and that measure is usually going to be a peak flow meter. That peak flow meter would give us a clue whether in fact the breathing problems are abnormal. It would simply say, you've got something that is causing you to wheeze, and that should be treated. I'm not so sure that it's critical that we figure out if it's asthma or COPD. It's just critical to see if you've got something that can be treated and reversed by one of these medications.

Rick:Next, [we'll go] to our live audience here in Chicago.

Mike:I just wanted to ask what effect cigarette smoking had on asthma, for any of the panel.

Dr. Richmond:
As we all know, if you take a lung function after we hit about 30 years of age, we see a gradual decline in our lung function. That's just normal. If you take a look at asthmatics, even well-controlled asthmatics, their fall in lung function will have a little steeper curve than will even normal non-asthmatics. Well-controlled asthmatics will do better. If you take a look at people with smoking or COPD, that fall is even more precipitous. If you would choose to continue to smoke and have asthma, that is the worst fall as far as losing your lung function over a much shorter period of time. That is a very, potentially lethal combination in your long-term prognosis.

Rick:As to the issue of smoke, I wonder have studies been done on this topic regarding direct smoke from the smoker and second-hand smoke?

Dr. Richmond:It's a big issue. There is no doubt that second-hand smoke is a major factor. We see that in the pediatric population. That is one of the major factors in pediatric asthma. Interestingly enough, it's not so much paternal smoking, it is maternal smoking, which has been clearly correlated with worsening pediatric asthma. I guess we could suggest that mom's going to be around more than dad and if mom's sitting there smoking, that airway irritation and bronchial constriction from cigarette smoke can be a major factor. But that is one of the major problems in pediatric asthma.

Greg:I'd like to tie maybe two issues that you brought up: one is coughing. I would say maybe once or twice a week I get into very bad coughing jags. That really disturbs me and worries me. I hurt from the coughing. Also, sometimes [I] wake between one and five in the morning. I'm taking Singulair [montelukast] and Advair [salmeterol/fluticasone]. I've been doing [my treatment] pretty religiously. I wondered if you had any suggestions.

Rick:And do you wake coughing?

Greg:Sometimes I do.

Dr. Richmond:Is this coughing associated with chest tightness and shortness of breath?

Greg:Yes.

Dr. Richmond:Nocturnal cough is an important problem that we see pretty regularly. Certainly cough can be a manifestation of asthma, without a doubt. We can see cough from other different phenomenon. We can see it from allergies. We can see it from post-nasal drip. We can see it in individuals as the presenting manifestation of recurring sinus disease. That, generally, is going to be pretty easy to figure out by history and from your symptoms.

Another important point, which again, is becoming much more prominent, at least prominently known in the last five to 10 years, is gastro-esophageal reflux [GERD] as a common cause of nocturnal cough and also increasing asthma. Those are some of the things we would think about. Now, if we go back and say, you've got nocturnal cough and you're taking Singulair, a leukotriene modifier, and an anti-inflammatory, that being your Advair, and things are not well-controlled, then we would want to sit down, we'd want to take a better look at your pulmonary functions. Get some breathing tests and see where that is. At that point, there would be, perhaps, an alteration in either the medication or the dose of medication you're on at this point in time.

Rick:I'm curious, does everyone with asthma cough, doctor?

Dr. Richmond:The vast majority of individuals who have asthma will cough. There is this phenomenon known as cough-equivalent asthma where the only manifestation of asthma is a cough. You don't have individuals who will wheeze. You'll not have them waking up with tightness. People with cough-equivalent asthma, generally it's not going to be a severe asthma, it's going to be milder asthma. I think one of the things that's interesting is yes, asthma can cause cough, but other different things that will potentiate asthma can cause cough that being gastro-esophageal reflux disease [GERD], which has always got to be considered, sinus disease and allergy.

Christian:Does the use of Azmacort [triamcinolone] affect glaucoma?

Dr. Richmond:The use of corticosteroids will increase intraocular pressure - glaucoma [which is] increasing pressure in the eye. When we give individuals oral steroids, frequently they'll go see their doctor because their vision is a little bit blurry. Most often, the ophthalmologist will say, "When you're off the steroids, come back, and we'll see if there's a problem then." Generally, the inhaled corticosteroids do not increase intraocular pressure at doses that are prescribed. There's no doubt that if we take a look at increasing inhaled doses at high dose, inhaled corticosteroids, that we can see systemic side effects, and we can certainly see cataracts and increase in intraocular pressure. But that would be [seen] at very high doses of inhaled corticosteroids.

Lydia:I read somewhere that asthmatics often develop dermatitis. I have a spot on my wrist, and it's like hives. It sort of pops up, and it'll go away, and it'll pop up again. I'm wondering if there is a correlation.

Dr. Richmond:There are certain conditions that are associated with asthma - one of which is atopic dermatitis. We generally will see that in the pediatric population. Atopic dermatitis, atopic eczema is a risk factor for asthma in the pediatric population. Usually, eczema in adults is not associated with that. This particular lesion, if it's a hivelike lesion, it's itchy, has a duration of less than 24 hours and if the skin is normal once that lesion goes away, then it sounds like a hive. I would suggest that it would be two independent processes going on here. You would have hives, and you would have asthma. Occasionally, people will have allergy exacerbations of both their asthma and hives. People who are walking around a dog and the dog licks them, and they get a hive, and then they wheeze. But, again, that's two different shock tissues being involved. I think the question here is what is the chronicity of this thing on your wrist? Is it something that has been there for a good long time, and does it clear rather rapidly? If it fails to clear rapidly, then I think it's time for the dermatologist to take a good look at it.

Joan:You mentioned tonight two important points. You in your practice you find that getting people to take medication on a regular basis has been an issue, and also that people can die from asthma whether they are diagnosed with mild or severe [asthma]. I have a two-part question here based on that article that was in the New England Journal of Medicine in regards to studies being done about people with mild asthma, of getting off their medications. There's no difference whether they've taken their medications or not, they've been fine. As an asthmatic, reading an article like this, my first question would be, can a person who has originally been diagnosed with mild asthma develop into a severe asthmatic whether they take medication or not? Also, reading this article, is it a form of playing a Russian roulette with our lives if we follow some advice like this?

Dr. Richmond:Those are very good questions. Let me do the first question, and then I will talk about this article ever so briefly and let people who have not read it, give you a little bit more information on it. Can an individual go from mild to severe asthma? Yes. Can individuals with mild asthma die from mild asthma? Again, mild asthma, as defined by having symptoms less than two times a week, having nocturnal awakening less than two times a month, using an albuterol inhaler refilling it less than two times a year, so that would be an individual who has rare symptoms. Can those people die? Yes, as I've suggested before, that people can run into a situation where they have acute asthma and die from that. We see it in the paper not infrequently here in Chicago. You can certainly progress. There is no doubt about that. We think that most individuals who are going to die from asthma are individuals who have more persistent disease, and that usually is going to be the case. Individuals who have asthma, they know they have asthma. They fail to take care of it appropriately. That is, they go to the emergency room regularly for their primary care, and once they leave the emergency room they take the medicine until it runs out, and then they are back on their own. And within a matter of weeks or so, they are back in the emergency room.

The article was published in the New England Journal [of Medicine]. It looked at intermittent use of inhaled corticosteroids versus daily use of corticosteroids asking the question "Are people well-controlled? Are their symptoms well-controlled?" It is a very interesting article - a very controversial article at this point in time, it does toss a wrench into the works. We take a look at individuals with asthma, and we want to decrease long-term persistent disease. We do not want to have any abnormalities in people's lungs when they get to be 95 years of age. When I first started teaching [patients about] asthma 30 years ago, I would tell patients when they walked in that if you died at 120, and I looked at your lungs at 120, your lungs would be absolutely normal if you had asthma, no matter what degree. That teaching is now no longer correct. It's very obvious that individuals with asthma will have changes in their airway. Airway remodeling is associated with airway inflammation. We do not know why people have airway remodeling. What we do know is that if we try to decrease airway inflammation, that we will decrease some airway remodeling. Therefore, we will have individuals who are more responsive. What is the long-term side effect of airway remodeling? You are not going to have nearly as responsive reversible airway disease. When you have a remodeled airway, it's going to be less responsive to therapy, in theory. So that's not what we want to do. I think that this particular [thing] is interesting because it raises the question, yes, can you be symptomatically controlled fairly well with intermittent use? And, again, a lot of people do that. The question that I think has to arise is, is what's that going to mean in the long-term with some individuals? And, again, this was a relatively short duration study. What is the long-term morbidity, that is, the side effects and mortality of this approach going to be? We have sort of an idea about that already because we've seen that asthma and deaths have increased when people use things intermittently.

Rick:Heidi from Dayton, Ohio, sent us this question. "There is so much I gave up when I developed asthma: scuba diving, making pottery, etc. Now that my asthma is under control, how can I tell if it's safe to resume my hobbies?"

Dr. Richmond:It's actually an interesting question because of the scuba question. As far as pottery making, if in fact you're doing extremely well, you can resume that right off the bat. Scuba and asthma - it's an area that 30 years ago, if you had asthma, you would be told not to scuba without doubt. As a result of airway abnormalities that individuals can have acute exacerbations when they are at depth, and occasionally people can blow a little of these air blebs, little alveoli and have a pneumothorax [air between the lung and the chest wall], potentially, obviously walking down the street would be a problem. But if you're 30 feet under water, you're going to have big problems.

Duke [University] has studied scuba diving and asthma, and they have a research center that looks at this regularly. Most dive schools now will require that if they will allow you to dive, to show that you have normal airway function on medication, that you have not had a recent exacerbation of your asthma, certainly within a two-week period of time and in that, ideally, a pre-dive pulmonary function has been shown to be normal. If you are a scuba diver and your asthma is absolutely under excellent control, and I must underline the word excellent, anything less than excellent, [and] I would be a bit concerned about diving.

Rick:[We have a question from] Melanie in Minneapolis, Minnesota who wrote, "Can having asthma make you feel fatigued?"

Carol:When my asthma was not in control, I was tired all the time. I did not want to do anything at all. But now that it's in control, I do not have the fatigue at all.

Dr. Richmond:Absolutely. I couldn't say it any better. It can cause significant fatigue, and as Carol suggested, once it's under good control, you should be normal. The question is, is this asthma or not? A cause of fatigue can be asthma, but again the most common complaint of anybody walking into any doctor's office, any doctor - whether it be an allergist, immunologist, a primary care doctor, a gynecologist - is fatigue.

Rick:Dr. Richmond, if there's one single piece of practical advice you could give people to help them better control their asthma, what would it be?

Dr. Richmond:I think they need to educate themselves. Nowadays with the Internet, I think you can certainly educate yourself about what asthma is, about the medications that are available and realize if you've got something more than an intermittent wheeze, that you need something more than just an albuterol inhaler.

Rick:Donna Staszak, in your opinion, what is the best thing asthma patients can do to take control of their disease?

Donna:I think don't just make those doctors' appointments. Get to those doctors' appointments and come to those appointments prepared. Three or four times a year, come with your questions, come with your concerns, come with a diary of days that weren't so good and what surrounded them. Let the doctor know how things are working, what can you do better, make the most of those visits. Stay in contact with your healthcare provider.

Rick:Carol, what advice would you have for fellow asthma patients out there who maybe want to get better control?

Carol:[I recommend] having a good relationship with your doctor and be willing to try new medications. If it wasn't for Dr. Richmond telling me to try new things, the Advair and the Xolair, I wouldn't have the control of my asthma as I do now.

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